Child Care Assistance Application

CHILD CARE ASSISTANCE APPLICATION
FOSTER CARE

Application Instructions

Read the application carefully and answer each question completely. If you have any questions about completing this application, you can call (605) 773-4766, toll-free 1-800-227-3020, or email CCS@state.sd.us.

If your provider is not registered or licensed, they must be pre-approved by Child Protection Services before we can issue any payments to that provider. Contact your child’s social worker prior to making arrangements for non-regulated care.

Visit the Online Child Care Search to locate a registered or licensed child care provider.

Child care providers will bill directly to Child Care Services for reimbursement. If your provider charges more than Child Care can pay, please contact your Child Protection Social Worker for additional options.

Applicant

First Name:

Middle:

Last Name:

Mailing Address:

City:

State:

Zip Code:

County:

Address where you live (if different than mailing):

City:

State:

Zip Code:

County:

Home Phone Number: - -

Work Phone Number: - -

CPS Social Worker's Name:

Phone Number: - -

CHILD INFORMATION

Complete for each foster child in your care.

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Foster Child Name (Last, First, Initial)	Race (optional) Check all that apply	Hispanic or Latino?	Sex	Date of Birth	Social Security Number (optional)	Date Child Placed in Care
Foster Child #1's Name:	Race: White/Caucasian Native American/Alaska Native Black/African American Native Hawaiian/Pacific Islander Asian/Oriental	Hispanic or Latino? YesNo	Sex:	Date of Birth:	SSN: - -	Date Child Place in Care:

White/Caucasian
Native American/Alaska Native
Black/African American
Native Hawaiian/Pacific Islander
Asian/Oriental

YesNo

- -

White/Caucasian
Native American/Alaska Native
Black/African American
Native Hawaiian/Pacific Islander
Asian/Oriental

YesNo

- -

Enter another child

EDUCATION or TRAINING

Do you need help paying for child care in order to go to school? YesNo

You must include an official school schedule for each adult family member attending school

Student's Name	Place of Education or Training	Credit Hours	Starting Date	Ending Date	Contact Person	Phone Number
Student #1's Name	Place of Education or Training:	Credit Hours:	Starting Date:	Ending Date:	Contact Person:	Phone Number: - -

Enter another student

FEDERAL REGULATIONS GOVERNING THE USE OF CHILD CARE FUNDS REQUIRE A RESPONSE TO THE FOLLOWING QUESTIONS:

Is any household member active duty in the U.S. Military? YesNo

If yes, please indicate who:

Is any household member in the National Guard or Military Reserve? YesNo

If yes, please indicate who:

What is the primary language spoken in your home?

Do your family assets exceed $1,000,000? YesNo